Prevalence of depression and associated factors among pregnant women attending antenatal care in public health institutions of Awabale Woreda, East Gojjam Zone, Northwestern Ethiopia: A cross-sectional study

Background Antenatal depression is a serious health problem and has negative consequences for the mother, fetus, and the entire family. However, it is a neglected component of care especially bay health care providers for women in pregnancy. The purpose of this study was to assess the prevalence of depression and associated factors among pregnant women attending antenatal clinics in public health institutions, in the Awabale Woreda. Method An institutional-based cross-sectional study was conducted in 2018 and a stratified sampling technique was used to select the study health institutions. All seven public health institutions in Awabale District were included to select 393 mothers and the sample size was proportionally allocated based on the number of target mothers. We used EpiData version 3.1software for data entry and SPSS version 20 software for cleaning and analysis. A Bivariable logistic regression analysis was used to identify the association between each outcome variable and the factor. Again, a multivariable logistic regression analysis was employed to identify factors associated with each outcome variable, and variables with a p-value less than 0.05 were taken as significant variables. Edinburgh Postnatal Depression Scale was used to declare the presence of antenatal depression with a cut point score of 13 and above. Result This study showed that 63(17.8%) pregnant mothers had antenatal depressive symptoms. Women who were employed 85% reduced to develop antenatal depression than housewives [AOR = 0.15(0.001–0.25)]. Pregnant women who attended high school and above educational level were 18 times more likely to develop antenatal depression than women who had no formal education [AOR18.15 (2.73–120.76)]. Women who had poor husband feeling on the current pregnancy were 4.94 more likely to develop antenatal depression than women who had good partner feeling on the current pregnancy [AOR = 4.94(95%CI: 1.78–13.72)]. Women who had a history of depression were 8.2 times to develop antenatal depression than women who had no history of depression [AOR = 8.22 (95%CI: 2.87–23.57)]. Conclusion This study revealed that approximately one-fifth of pregnant women developed antenatal depression. Women’s occupational status, educational status, previous history of depression, and poor husband feeling on the current pregnancy were the significant factors of antenatal depression.

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Introduction
Pregnancy is the period from the fertilization of the egg by sperm to the delivery of the fetus and usually lasts 40 weeks. Starting from the last normal menstrual period, it is divided into three trimesters, each lasting three months [1]. It is a distinctive social and biological event in a woman's life [2,3].
A depressive disorder is an illness that involves the body, mood, and thoughts in which the person has unrelenting sentiments of unhappiness and irrelevance and a lack of aspiration to engage in previously enjoyable activities that last more than two weeks.
When these sentiments last for a short period, it may be a case of feeling sadness [4]. It is the most frequent expressive disorder in women and the general population, and one in every five people has depression with more than the twofold increased incidence in women than men [2]. Psychiatric history, stressful life events, lack of social support, teenage pregnancy, low educational level, low income, and violence against women are the factors that make depression prevalent in pregnant women [3,5,6].
Antenatal depression means depression that starts from conception to delivery [7].
Pregnant women experience symptoms similar to general depression and may interfere with their normal day-to-day activities. It may occur at any stage of pregnancy and can be a reaction to the pregnancy itself, due to health issues, major life stresses, genetic and biochemical basis, or due to a continuation or relapse of a pre-pregnancy condition [8]. Antenatal depression ends with poor fetal, infant development, and maternal outcomes like small for gestational age, prematurity, intrauterine growth problem; postnatal depression preeclampsia, anemia; educational problem, malnutrition, respiratory disorders, and mental retardation [9][10][11][12][13].
Most of the researches was undertake on postnatal depression. The majority of studies on the prevalence of antenatal depression and associated factors have been conducted in developed countries [14]. However, there is a paucity of studies, which examined the prevalence and associated factors of antenatal depression in low-income countries like Ethiopia. There are studies undertaken on antenatal depression. Yet, they focus on adolescent pregnant women and women's that have antenatal care service in hospital settings [3]. Those studies have a limitation on addressing pregnant women in all age groups. In addition, they are likely to have a bias because most women with hindrance in their pregnancies are likely to seek antenatal care services in hospitals. There are studies, which were excluded illiterate women from the study [15]. This may lead to selection bias because educational status has a significant association with antenatal depression as described in the literature.
The Federal Democratic Republic of Ethiopia National Mental Health Strategy promotes a decentralized approach in which mental health services are to be offered from local health institutions up to tertiary hospitals to ensure access to treatment near to their living area and with a less restraining setting [16]. This study aimed to assess the prevalence of depression and associated factors among pregnant women attending antenatal clinics in public health institutions, in Awabale Woreda.

Study area and period
The study was conducted in 2018 in Awabale woreda which is found in the Amhara region, North West Ethiopia, which is located 300 km from Addis Ababa, the capital city of Ethiopia, and located 265 km from Bihar Dar, the capital city of the Amhara region.

Study design
An institutional-based cross-sectional study design was employed.

Study participants
All pregnant women attending antenatal care in Awabale Woreda public health institutions were the source population. All pregnant women attending antenatal care in selected public health institutions during the study period were the study population.
Pregnant women at any age of gestation who come to the selected health institutions for antenatal care visits during the study period were included in the study and we excluded those who were critically ill during the data collection period.

Sample size
The required sample size was calculated using a single population proportion formula with the assumption of 31.2 % of depression during pregnancy from a study conducted in Adama, Ethiopia[18] and 5% marginal error (w), a standard Z score of 1.96 corresponding to a 95% confidence interval (Za/2),and 10% non-response rate. n= (Za/2)² p (1-p) By considering 10% non response rate=32.98. Then the required sample size was 363.

Sampling techniques
Stratified sampling was undertaken to select the study of health institutions. All seven public health institutions in Awabale District were included and the sample size was proportionally allocated based on the number of target mothers. All eligible and consenting women attending for antenatal care during the study period were taken into the study consecutively until the sample size was reached.

Study variables
Dependent variable: depression during pregnancy (present/absent)

Independent variables
Socio-demographic factors: maternal age, educational status, marital status, occupation of the mother and family, monthly income Postnatal Depression Scale (EPDS) score of 13 and above [19,20] Social support: Is support from the community ranges from a score of 3 to 14 according to the OSLO social support scale. A score of 3-8 is poor support, 9-11 is moderate support, and 12-14 is strong support.

Data collection procedure and data quality control
To assure the data quality, data were collected with face-to-face interviews by attained BSc Midwife in each institution after one-day data collection training was given to them together with two MSc holder supervisors. The questionnaire was structured and pre-tested which was first prepared in English and translated to local (Amharic) language and then again translated back to English. A pretest was conducted on 18 pregnant women of the sample size other than the study area and the necessary correction on the tool was employed accordingly.

Data collection and measurement tool
EPDS was administered to detect symptoms of depression and their socio-demographic data along with obstetric and psychosocial factors. EPDS is a 10 item questionnaire scored from zero up to three (higher score indicating more depressive symptoms), that has been validated for detecting depression in antepartum and postpartum samples in many countries. The instrument was validated in public health centers in Addis Ababa for postpartum use and showed a sensitivity of 84.6 % and specificity of 77.0 % at the cutoff score of 7/8 [20]. Those pregnant women who score 13 and above were categorized as depressed women while pregnant women who scored below 13 were considered as non-depressed women.
The OSLO-3 item social support scale was used to measure social support for pregnant women. Partners feeling on the current pregnancy can be defined as the sensation of pregnant women about the feeling of their partners concerning the current pregnancy. It was measured by asking whether her partner feeling on the current pregnancy was good or poor. Similarly, husband/partner support was assessed by asking women emotions about their partner's support to the health of the fetus and continuation of pregnancy. A structured Amharic version questioner containing socio-demographic characteristics, obstetric history, and psychosocial history, history of clinical factors, history of violence, and history of substance abuse was administered.

Data analysis technique
EpiData version 3.1 software was used for data entry and SPSS version 20 was used for analysis. Bivariate logistic regression was employed to identify an association between independent and dependent variables. Variables having a P-value of less than 0.2 in the bivariate logistic regression analysis were fitted into the multivariable logistic regression model to manage confounders. The 95% confidence interval of odds ratio was computed and a variable having P-value less than 0.05 in the multivariable logistic regression analysis was considered as statistically significant. The result was presented by tables and text.

Ethical consideration
The study was approved by the Institutional Health Research Ethics Review Committee of Debre Markos University, College of health science. An official letter was written from Debre Markos University to the selected health institutions. The participants enrolled in the study were informed about the study objectives, expected outcomes, benefits, and the risks associated with it. Written consent was taken from the participants before the interview.

Socio-demographic factors
Three hundred fifty-four study participants gave the response to the questionnaire, giving a response rate of 97.5. %. The majorities of the respondents were Amhara 351 (99.2 %) and orthodox by religion were 293 (82.8 %). Three hundred thirty-five (94.6 %) of the women were married and 150(44.8%) were farmers in their occupation (Table   1).

Obstetric and clinical characteristics
Two hundred nine (59%) of the respondents had a history of pregnancy. Around 58(16.4%) and 9 (2.5%) of the respondents had a previous history of depression and a family history of depression respectively and 38(10.7%) had a history of chronic illness (Table 2). Seventy-three (20.6%) of women's had a history of violence in their lifetime ( Table 3).

Prevalence of antenatal depression
About 63 (17.8%) of respondents had antenatal depression (EPDS score ≥13). More than half (57%) of the respondents were able to laugh and see the funny side of things.
On the other hand, (58.5%) of pregnant women felt sad or miserable most of the time

Discussion
This study aimed to assess the prevalence of depression and associated factors among pregnant women attending antenatal care in public health institutions of Awabale Woreda, East Gojam zone, Amhara National Regional State, Northwestern Ethiopia, during March-April 2018. The study finding of antenatal depression (17.8%) in the current study was in line with similar reports in Bangladesh (18%) and Ethiopia (19.9%) [21,22]. The finding of this research was lower than the studies done in China (28.5%) [7], 29.9% and 31.2% in Ethiopia [19,23], 33.8 in Tanzania [15], 38.5% and 47% in South Africa [15,24]. This difference might be due to the difference in their population demographic characteristics, study design, period, and the difference in their investigatory or diagnostic tools.
Prevalence of antenatal depression was associated with the occupation of the women, educational status, history of depression, and poor husband feeling in the current pregnancy. Women who were running their business were 85% reduced to develop antenatal depression than housewives [AOR=0.15(0.001-0. 25)]. This might be due to that, those who have their own business may have social relationships and putting women economically independent [25]. Also, those housewife women are expending most of their time at home and alone. This loneliness may put them in depression [26].
Women with high school and above educational levels were 18 times more likely to develop antenatal depression than women who had no formal education ]. This might be due to their difficulty in managing interpersonal relationship strains related to academic performance pressure and inability to translate their additional education into better mental health outcomes [27].On the other hand, different studies in different countries report the association of lower educational status with an increased prevalence of antenatal depression [21,25,28].
Those women who had a history of depression had 7.26 times the odds of developing antenatal depression than women who had no history of depression [AOR=7.26(95%CI: 2.52-20.93)]. The comparable association was also reported from studies conducted in developing and developed countries [19]. This might be due to physical and hormonal changes occurring during pregnancy and the recurrence of depressive symptoms [25].
Conversely, the personal history of previous psychiatric illness was not found to be a significant risk factor for antenatal depression in a study conducted in Lahore, Pakistan [29].
Pregnant women who had poor husband feeling on the current pregnancy were 4.86 times more likely to develop antenatal depression as compared with good husband feeling towards current pregnancy [AOR=4.86(95%CI: 1.74-13.58)]. This is possible because those partners who had good feelings about the pregnancy authorize the women on their home responsibilities and help women to have cared for their health and the health of the fetus. It might be also due to the effect of a poor husband's feeling on diminishing partner support [19].
The finding of this study shows no significant association between partner occupational status, trimester, unplanned pregnancy, social support, history of violence, and substance use in the multivariable model. This result seems consistent with other findings [19,30]. On the other hand, contrary to this finding, those women who had a history of substance use had a higher risk of developing antenatal depression [15].

Limitations of the study
We cannot be certain that individuals with an EPDS score ≥ of 13 had depressive illness without confirmation. Moreover, the EPDS cut-off score varies in different kinds of literature and this could be the reason for the different prevalence of antenatal depression in different kinds of literature. Concluding about partner feeling on the current pregnancy by asking pregnant women was an indirect conclusion and may have a biased result. Social desirability bias due to face-to-face interviews and using crosssectional studies which do not show causality is also the limitation of this study.

Strength of the study
The main strength of this study was the data source. It used a primary data source during data collection.

Conclusion
This study showed that 17.8% of pregnant women develop antenatal depression. These

Availability of data and materials
The data that support the findings of this study are available, but some restrictions may apply to the availability of these data as there are some sensitive issues. However, data are available from the corresponding authors upon reasonable request.

Introduction
Pregnancy is the period from the fertilization of the egg by sperm to the delivery of the fetus and usually lasts 40 weeks. Starting from the last normal menstrual period, it is divided into three trimesters, each lasting three months [1]. It is a distinctive social and biological event in a woman's life [2,3].
A depressive disorder is an illness that involves the body, mood, and thoughts in which the person has unrelenting sentiments of unhappiness and irrelevance and a lack of aspiration to engage in previously enjoyable activities that last more than two weeks.
When these sentiments last for a short period, it may be a case of feeling sadness [4]. It is the most frequent expressive disorder in women and the general population, and one in every five people has depression with more than the twofold increased incidence in women than men [2]. Psychiatric history, stressful life events, lack of social support, teenage pregnancy, low educational level, low income, and violence against women are the factors that make depression prevalent in pregnant women [3,5,6].
Antenatal depression means depression that starts from conception to delivery [7].
Pregnant women experience symptoms similar to general depression and may interfere with their normal day-to-day activities. It may occur at any stage of pregnancy and can be a reaction to the pregnancy itself, due to health issues, major life stresses, genetic and biochemical basis, or due to a continuation or relapse of a pre-pregnancy condition [8]. Antenatal depression ends with poor fetal, infant development, and maternal outcomes like small for gestational age, prematurity, intrauterine growth problem; postnatal depression preeclampsia, anemia; educational problem, malnutrition, respiratory disorders, and mental retardation [9][10][11][12][13].
Most of the researches was undertake on postnatal depression. The majority of studies on the prevalence of antenatal depression and associated factors have been conducted in developed countries [14]. However, there is a paucity of studies, which examined the prevalence and associated factors of antenatal depression in low-income countries like Ethiopia. There are studies undertaken on antenatal depression. Yet, they focus on adolescent pregnant women and women's that have antenatal care service in hospital settings [3]. Those studies have a limitation on addressing pregnant women in all age groups. In addition, they are likely to have a bias because most women with hindrance in their pregnancies are likely to seek antenatal care services in hospitals. There are studies, which were excluded illiterate women from the study [15]. This may lead to selection bias because educational status has a significant association with antenatal depression as described in the literature.
The Federal Democratic Republic of Ethiopia National Mental Health Strategy promotes a decentralized approach in which mental health services are to be offered from local health institutions up to tertiary hospitals to ensure access to treatment near to their living area and with a less restraining setting [16]. This study aimed to assess the prevalence of depression and associated factors among pregnant women attending antenatal clinics in public health institutions, in Awabale Woreda.

Study area and period
The study was conducted in 2018 in Awabale woreda which is found in the Amhara region, North West Ethiopia, which is located 300 km from Addis Ababa, the capital city of Ethiopia, and located 265 km from Bihar Dar, the capital city of the Amhara region.

Study design
An institutional-based cross-sectional study design was employed.

Study participants
All pregnant women attending antenatal care in Awabale Woreda public health institutions were the source population. And all pregnant women attending antenatal care in selected public health institutions during the study period were the study population. Pregnant women at any age of gestation who come to the selected health institutions for antenatal care visits during the study period were included in the study and we excluded those who were critically ill during the data collection period.

Sample size
The required sample size was calculated using a single population proportion formula with the assumption of 31.2 % of depression during pregnancy from a study conducted in Adama, Ethiopia[18] and 5% marginal error (w), a standard Z score of 1.96 corresponding to a 95% confidence interval (Za/2),and 10% non-response rate.

Sampling techniques
Stratified sampling was undertaken to select the study of health institutions. Postnatal Depression Scale (EPDS) score of 13 and above [19,20] Social support: Is support from the community ranges from a score of 3 to 14 according to the OSLO social support scale. A score of 3-8 is poor support, 9-11 is moderate support, and 12-14 is strong support.

Data collection procedure and data quality control
To assure the data quality, data were collected with face-to-face interviews by attained BSc Midwife in each institution after one-day data collection training was given to them together with two MSc holder supervisors. The questionnaire was structured and pretested which was first prepared in English and translated to local (Amharic) language and then again translated back to English. A pretest was conducted on 18 pregnant women of the sample size other than the study area and the necessary correction on the tool was employed accordingly.

Data analysis technique
EpiData version 3.1 software was used for data entry and SPSS version 20 was used for analysis. Bivariate logistic regression was employed to identify an association between independent and dependent variables. Variables having a P-value of less than 0.2 in the bivariate logistic regression analysis were fitted into the multivariable logistic regression model to manage confounders. The 95% confidence interval of odds ratio was computed and a variable having P-value less than 0.05 in the multivariable logistic regression analysis was considered as statistically significant. The result was presented by tables and text.

Ethical consideration
The study was approved by the Institutional Health Research Ethics Review Committee of Debre Markos University, College of health science. An official letter was written from Debre Markos University to the selected health institutions. The participants enrolled in the study were informed about the study objectives, expected outcomes, benefits, and the risks associated with it. Written consent was taken from the participants before the interview.

Socio-demographic factors
Three hundred fifty-four study participants gave the response to the questionnaire,  (Table   1).

Obstetric and clinical characteristics
Two hundred nine (59%) of the respondents had a history of pregnancy. Around 58(16.4%) and 9 (2.5%) of the respondents had a previous history of depression and a family history of depression respectively and 38(10.7%) had a history of chronic illness (Table 2). Seventy-three (20.6%) of women's had a history of violence in their lifetime ( Table 3).

Prevalence of antenatal depression
About 63 (17.8%) of respondents had antenatal depression (EPDS score ≥13). More than half (57%) of the respondents were able to laugh and see the funny side of things.

Discussion
This study aimed to assess the prevalence of depression and associated factors among pregnant women attending antenatal care in public health institutions of Awabale Woreda, East Gojam zone, Amhara National Regional State, Northwestern Ethiopia, during March-April 2018. The study finding of antenatal depression (17.8%) in the current study was in line with similar reports in Bangladesh (18%) and Ethiopia (19.9%) [21,22]. The finding of this research was lower than the studies done in China (28.5%) [7], 29.9% and 31.2% in Ethiopia [19,23], 33.8 in Tanzania [15], 38.5% and 47% in South Africa [15,24]. This difference might be due to the difference in their population demographic characteristics, study design, period, and the difference in their investigatory or diagnostic tools.
Prevalence of antenatal depression was associated with the occupation of the women, educational status, history of depression, and poor husband feeling in the current pregnancy. Women who were running their business were 85% reduced to develop antenatal depression than housewives [AOR=0.15(0.001-0. 25)]. This might be due to that, those who have their own business may have social relationships and putting women economically independent [25]. Also, those housewife women are expending most of their time at home and alone. This loneliness may put them in depression [26].  [19]. This might be due to physical and hormonal changes occurring during pregnancy and the recurrence of depressive symptoms [25].
Conversely, the personal history of previous psychiatric illness was not found to be a significant risk factor for antenatal depression in a study conducted in Lahore, Pakistan [29].  [19].
The finding of this study shows no significant association between partner occupational status, trimester, unplanned pregnancy, social support, history of violence, and substance use in the multivariable model. This result seems consistent with other findings [19,30]. On the other hand, contrary to this finding, those women who had a history of substance use had a higher risk of developing antenatal depression [15].

Limitations of the study
We cannot be certain that individuals with an EPDS score ≥ of 13 had depressive illness without confirmation. Moreover, the EPDS cut-off score varies in different kinds of literature and this could be the reason for the different prevalence of antenatal depression in different kinds of literature. Concluding about partner feeling on the current pregnancy by asking pregnant women was an indirect conclusion and may have a biased result. Social desirability bias due to face-to-face interviews and using crosssectional studies which do not show causality is also the limitation of this study.

Strength of the study
The main strength of this study was the data source. It used a primary data source during data collection.

Conclusion
This study showed that 17.8% of pregnant women develop antenatal depression. These notify a higher prevalence of antenatal depression in women attending antenatal care services at public health institutions. Women's occupational statuses, educational status, previous history of depression, and poor husband feeling on the current pregnancy were significant factors for antenatal depression.

Responses for reviewers
Thank you all for your constructive suggestions and comments.
Reviewer #1: 1. The main reasons that we did this study were:  Most of the researches was undertaking on postnatal depression.
 The majority of studies have been conducted in developed countries.
 There are studies undertaken on antenatal depression. Yet, they focus on adolescent pregnant women and women's that have antenatal care service in hospital settings that couldn't include in all public health settings.
 Those studies have a limitation on addressing pregnant women in all age groups.
 In addition, they are likely to have a bias because most women with hindrance in their pregnancies are likely to seek antenatal care services in hospitals.
 There are studies, which were excluded illiterate women from the study.

The methods
 We have revised this section based on the given comment. o There are studies, which were excluded illiterate women from the study.

Reviewer #3
Dear reviewer #3, as my view I addressed all of your comments, but some comments were accepted and corrections were done on the manuscript.
 The main reasons that we did this study were:  Most of the researches was undertaking on postnatal depression.
 The majority of studies have been conducted in developed countries.
 There are studies undertaken on antenatal depression. Yet, they focus on adolescent pregnant women and women's that have antenatal care service in hospital settings.
 Those studies have a limitation on addressing pregnant women in all age groups.
 In addition, they are likely to have a bias because most women with hindrance in their pregnancies are likely to seek antenatal care services in hospitals.
 There are studies, which were excluded illiterate women from the study.  Even though we have used a stratified sampling method to select public health institutions we selected the samples consecutively because they had no sampling frame and difficult to do it with every k th interval (it was in the outpatient setting).
 Adama and awabel may not have different health care services because they are led by similar health care delivery systems ( health care providers, health institutions, and other related services) guided by a similar agency like the ministry of health.
The population may have socio-cultural and/or economical differences but we can use it since there is no other study near to awabel other than Adama.
 Since there is no validated tool for antenatal depression and the study populations were mothers, it would be better to use a validated tool than simple tool  The fitness model was assessed by chi-square test and the strength of the association was measured by adjusted odds ratio.
 Our base to classify rural-urban was based on residence.
 Income was categorized based on a previous study.